Medical Coding Rights

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.   On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation. All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.     The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine.  If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients. Claims for reimbursement will be priced as desc

Effective January 1, 2021, the RHC payment limit per visit for Calendar Year (CY) 2021 is $87.52. This payment limit applies to independent RHCs and RHCs that are provider-based to a hospital with 50 or more beds. Beginning April 1, 2021, the RHCs will begin to receive an increase in their payment limit per visit over an 8-year period, with a prescribed amount for each year from 2021, through 2028.  Then, in subsequent years, the limit is updated by the percentage increase in MEI applicable to primary care services furnished as of the first day of that year. The RHC payment limit per visit over an 8-year period is as follows, In 2021, after March 31, at $100 per visit In 2022, at $113 per visit In 2023, at $126 per visit In 2024, at $139 per visit In 2025, at $152 per visit In 2026, at $165 per visit In 2027, at $178 per visit In 2028, at $190 per visit

The Biden-Harris Administration is providing free access to COVID-19 vaccines for every adult living in the United States.  Accordingly, the Health Resources and Services Administration’s (HRSA) COVID-19 Coverage Assistance Fund (CAF) will cover the costs of administering COVID-19 vaccines to patients whose health insurance doesn’t cover vaccine administration fees, or does but typically has patient cost-sharing.  While patients cannot be billed directly for the COVID-19 vaccine fees, costs to health care providers on the front lines for administering COVID-19 vaccines to underinsured patients will now be fully covered through CAF, subject to available funding.  As vaccination efforts accelerate, patients will increasingly gain access to COVID-19 vaccines at locations near where they live with providers they trust. Providers are eligible for claims reimbursement if they have administered Food and Drug Administration (FDA) authorized COVID-19 vaccines under an Emergency Use Authorizatio

Modifier QW The Medicare and Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level.  To be recognized as a test that can be performed in a facility having a CLIA certificate of waiver for listed below CPT codes and the modifier QW must be added . The CMS released updates for adding modifier QW for COVID-19 lab codes with effective date of service. The Medicare contractor shall permit the use of code 87636 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after October 6, 2020 and effective from July 1, 2021 The Medicare contractor shall permit the use of code  87428 QW   for claims submitted by facilities with a valid, current CLIA certificate of waiver with   dates of service on or after November 10, 2020. The Medicare contractor shall permit the use of code  87811 QW  for claims s

The national public health emergency has been extended from April 20, 2021, to July 19, 2021. Below is an overview of how that extension affects temporary provisions for COVID-19 testing and testing-related services for major payers UHC Individual Exchange, Individual and Group Market health plans: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network COVID-19 tests and testing-related services, including testing-related telehealth visits. Medicare Advantage: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network tests for COVID-19. Medicaid : State-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable. Aetna Aetna’s liberalized coverage of Co

All Medicare providers and suppliers who requested and received CAAPs that we began recovering those payments as early as March 30, 2021, depending upon the 1 year anniversary of when you received your first payment.  It also gives information on how to identify recovered payments.  Title V (Section 2501) of the Continuing Appropriations Act, 2021 and Other Extensions Act, enacted on October 1, 2020, amended the CAAP repayment terms for all providers and suppliers who requested and received CAAPs during the COVID-19 PHE and established a lower interest rate of 4% for any demanded overpayments to recover CAAP balances due.  The CAAP repayment terms provide as follows, Repayment begins 1 year starting from the date we issued your first CAAP. Beginning 1 year from the date we issued the CAAP and continuing for 11 months, we’ll recover the CAAP from Medicare payments due to providers and suppliers at a rate of 25%. After the end of this 11 month period, we’ll continue to recover the remain

CMS will pay for phone calls using codes 99441—99443. The 4/30/20 rule adds these to the telehealth list and increased payment for these services These codes previously had a non-covered status and the  Physicians, nurse practitioners, and physician assistants should use codes 99441—99443 99441 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion 99442 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within t

The CMS fee schedule changes for audio-only codes, providers will continue to be reimbursed for audio-only visits at the rate they would receive for audio-video or in-person codes.  The CMS rates for audio-only telephonic evaluation and management (E/M) codes, as well as virtual check-ins (which may be done by telephone) and e-visits for established patients for dates of service on or after March 1, 2020. Audio-only visits and other services not requiring video technology include Audio-only (telephone) E/M services  99441 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion 99442 - Telephone evaluation and management s

The below list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth during the PHE (Public Health Emergency) CPT Short Descriptor 77427 Radiation tx management x5 90785 Psytx complex interactive 90791 Psych diagnostic evaluation 90792 Psych diag eval w/med srvcs 90832 Psytx w pt 30 minutes 90833 Psytx w pt w e/m 30 min 90834 Psytx w pt 45 minutes 90836 Psytx w pt w e/m 45 min 90837 Psytx w pt 60 minutes 90838 Psytx w pt w e/m 60 min 90839 Psytx crisis initial 60 min 90840 Psytx crisis ea addl 30 min 90845 Psychoanalysis 90846 Family psytx w/o pt 50 min 90847 Family psytx w/pt 50 min 90853 Group psychotherapy 90875 Psychophysiological therapy 90951 Esrd serv 4 visits p mo <2yr 90952 Esrd serv 2-3 vsts p mo <2yr 90953 Esrd serv 1 visit p mo <2yrs 90954 Esrd serv 4 vsts p mo 2-11 90955 Esrd srv 2-3 vsts p mo 2-11 90956 Esrd srv 1 visit p mo 2-11 90957 Esrd srv 4 vsts p mo 12-19 90958 Esrd s

The AMA released on Jan 19, 2021,  A fourth COVID-19 vaccine code has been released by the American Medical Association, along with an administration code.   91303 - Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use 0031A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5x1010 viral particles/0.5mL dosage, single dose The Janssen COVID-19 vaccine EUA/approval, providers will report 0031A for the administration of vaccine 91303 Note that Janssen is a single-dose vaccine, requiring a single administration. Providers will not have any reason to report 0031A more than once for a patient in any given year.  The AMA has also rel